Quality in Endoscopy: ERCP, Munich 2011
Jean Pierre Charton
EVK
Duesseldorf, Germany
Ampullectomy -
Papillectomy
Quality in Endoscopy: ERCP, Munich 2011
Guidelines
ASGE
The role of endoscopy in ampullary and duodenal
adenomas
GIE 2006
ESGE
Prophylaxis of post-ERCP-pancreatitis
Endoscopy 2010
Quality in Endoscopy: ERCP, Munich 2011
Ampullary tumors
Adenoma-carcinoma-sequence
→ complete resection necessary
Stolte Scand J Gastroenterol 1996
Quality in Endoscopy: ERCP, Munich 2011
therapy of ampullary tumors
traditional: surgical therapy
DeCastro Surgery 2004
Norton GIE 2002
Di Giorgio WJS 2005
method mortality complications recurrences
transduodenal
ampullectomy
0-4% 0-25%
5-30%
pancreatico-
duodenectomy
3-5% 25-40% 0%
Quality in Endoscopy: ERCP, Munich 2011
Biopsy?
• suspicious ampullary lesions should be biopsied
before endoscopic resection is attempted
• firmness, ulceration, non-lifting, friability
ASGE
ASGE
guideline
guideline
GIE 2006
GIE 2006
false-negative biopsy: 16-47%
Yamaguchi GIE 1990, De Castro
Surgery 2004, Lee GIE 2006, Irani
GIE 2009, Kim Ann Surg Oncol 2009
Quality in Endoscopy: ERCP, Munich 2011
EUS / IDUS?
assessment of
• depth of infiltration
• intraductal extension
• periampullary lymph nodes
Quality in Endoscopy: ERCP, Munich 2011
EUS / IDUS?
Prospective, histopathologically controlled study
N=40 (30 surgery, 10 ER)
Adenocarcinoma: 33 patients (14 pT1, 11 pT2, 8 pT3-4)
Adenoma: 7 patients
EUS IDUS
Accuracy T staging (all patients)
Adenoma, pT1
pT2
pT3,4
62%
45%
88%
86%
64%
75%
Accuracy T staging (endoscopically
treated patients)
Ductal infiltration diagnosed
80%
89%
100%
90%
Ito GIE 2007
Quality in Endoscopy: ERCP, Munich 2011
EUS / IDUS?
No agreement on necessity of EUS / IDUS
ASGE guideline GIE 2006
EUS / IDUS: tendency of overestimation of
ampullary tumors
Ito GIE 2007
Ito Dig Endosc 2011
Quality in Endoscopy: ERCP, Munich 2011
Endoscopic resection - technique
• Submucosal Injection?
Saline solution, epinephrine, methylene blue,
methylcellulose
ASGE
ASGE
guideline
guideline
GIE 2006
GIE 2006
Recommended in laterally spreading / giant tumors
Hopper GIE 2010
Hopper GIE 2010
Insufficient data
Quality in Endoscopy: ERCP, Munich 2011
Endoscopic resection - technique
Quality in Endoscopy: ERCP, Munich 2011
Retrieval of the resected specimen
Quality in Endoscopy: ERCP, Munich 2011
Papillectomy - results
*intraductal max. 1cm
Catalano GIE 2004
Cheng GIE 2004
Bohnacker GIE 2005
Irani GIE 2009
author n CA intraductal surgery recurrence
Catalano
2004
103 6% 0 16% 19%
Cheng
2005
55 13% 11% 13% 33%
Bohnacker
2005
106 8% 29%* 19% 15%
Irani
2009
102 8% n.m.* 16% 8%
all 366 8,5% 16,4% 16.9%
Quality in Endoscopy: ERCP, Munich 2011
Endoscopic resection and…
• biliary EST
• pancreatic EST
& stenting
Catalano GIE 2004, Cheng GIE 2004, Bohnacker GIE
2005, Irani GIE 2009, ASGE guideline GIE 2006
Quality in Endoscopy: ERCP, Munich 2011
Complication: bleeding
treated with injection, hot-biopsy forceps and/or clips
author n bleeding
Catalano
GIE 2004
103 2%
Cheng
GIE 2004
55 7%
Bohnacker
GIE 2005
106 1%
Irani
GIE 2009
102 5%
all 366 3.2%
Quality in Endoscopy: ERCP, Munich 2011
further complications: perforation, stenosis
Catalano GIE 2004, Cheng GIE
2004, Bohnacker GIE 2005, Irani
GIE 2009
author perforation stenosis mortality
Catalano
2004
0% 3% 0%
Cheng
2004
2% 3.6% 0%
Bohnacker
2005
0% 0% 0%
Irani
2009
2% 3% 0%
Hopper
2010
0% n.m. 0%
Quality in Endoscopy: ERCP, Munich 2011
ESGE guideline:
prophylaxis of post-ERCP-pancreatitis (PEP)
• The number of cannulation attempts should be minimized
• Number of injections and volume of contrast medium should be kept as low
as possible
• Endoscopic papillary ballon dilation: higher incidence of PEP than EST
• Prophylactic pancreatic stent placement (short, 5fr) in high-risk patients
Dumonceau Endoscopy 2010
,
Freeman NEJM 1996, Williams Endoscopy 2007, Masci
Endoscopy 2003, Baron AJG 2004, Weinberg Cochrane
database Syst Rev 2006, Andriulli Digestion 2007, Singh
GIE 2004
Quality in Endoscopy: ERCP, Munich 2011
post-ERCP-pancreatitis (PEP)
post-papillectomy-pancreatitis
Prophylaxis of PEP: stenting of the pancreatic duct
author n pancreatitis
stent
pancreatitis
no stent
p
Catalano
2004
103 3% 17% n.m.
Cheng
2004
55 10% 25% 0.33
Bohnacker
2005
106 11% 14% >0.05
Harewood
2005
19 0% 33% 0.02
Nguyen
2010
36 0% n.a. n.a.
Quality in Endoscopy: ERCP, Munich 2011
Pancreatic duct stenting
any exception for pancreatic stenting?
Quality in Endoscopy: ERCP, Munich 2011
endoscopic resectability
• intraductal tumor-growth
>10mm: surgical resection
Cheng GIE 2004
Irani GIE 2009
Quality in Endoscopy: ERCP, Munich 2011
endoscopic resectability
Bohnacker GIE 2005
HGIN + intraductal tumor growth → surgery
Seewald GIE 2006
intraductal extraductal
patients 31 75
HGIN 11 (35.5%) 7 (9.3%)
endoscopic
resection
46% 83% (p<0.05)
recurrence 4 (14%) 11 (15%)
surgery 37% 12%
Quality in Endoscopy: ERCP, Munich 2011
ampullary adenomas with HGIN
„Is endoscopic papillectomy safe?“
N=33
Coexistence of cancer in patients with
HGIN (biopsy): 50%
LGIN (biopsy): 15%
Rate of recurrence
HGIN: 80%
Tumor size:
LGIN: 1.27 +/- 0.89cm
HGIN: 1.81 +/- 0.99cm
CA: 1.98 +/- 1.08cm
Tumor size >1,5cm: HGIN/CA (sens. 55%, spec. 80%)
Kim Ann Surg Oncol 2009
Quality in Endoscopy: ERCP, Munich 2011
Yoon GIE 2007
Woo J Gastroenterol Hepatol 2009
author n histology results follow-up
Yoon
2007
439
21
18
all
HGIN
focal pT1*
L0 V0, no LN-met.,
no recurrence
27
months
Woo
2009
216
5
13
all
HGIN
pT1 < 2cm**
no LN-Met., 5-y: 100%
no LN-Met., no recurrence
36
months
* mucosal, <25% of adenoma
** well-diff., L0 V0
HGIN / papillary cancer
endoscopic and surgical resection specimen
Quality in Endoscopy: ERCP, Munich 2011
conclusions
• safe, definite histology, good results
• criteria of successful endoscopic resection:
histology: max. HGIN
risk factor: intraductal extension
tumor size: „no limit“
• recurrences: endoscopic follow-up necessary
• complications: endoscopic / conservative management
endoscopic resection of papillary adenoma